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FOR OFFICE USE: �+.. r --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ./....... ---------------------------------------------------- --- [Complete in Duplicate]! Date Issued - -------------------------------------------------------- i This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h in described. This application is made in compliant with County + Ordinance No. 5499. ` JOB ADDRESS AND LOC TION- .. - c ` '� ---i / ' -...�1(f'` ----�s�..tC---A-MA Owner's Name 'rte Phone.-----------------------------•-•--- P Address ------ - -------------- •-------�`��'~r'�1� - Contractor's Name---------- !Ll = ... Phone. ............ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ________ Number of bedrooms ________ Number 4F baths ________ Lot size _____________________________ ---------- Water Supply: Public system C1Community system [IPrivate Depth to Water Table O__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ AdobeHardpan ❑ Previous Application Made: {If yes,date____-----------_____) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance from nearest well__ _ Distance�from�foundation_____!!-if__--_.__.Mat rial----- ^.._____.. No. of compartments ---�' Size.�,iCg_ J!5�.Li uid de th____._----- ________Ca acit C p q R P Y rl Dispos Field: Distance from nearest well_.__` a Distance from foundation_____`_________.Distance to nearest lot line_S____________ Number of lines__________�__________________ Length of each line_______±-a__'____....Width of trench_____`Z.__----_-_---____________ VN Type of filter material___ Z.__Depth of filter material.._._.I$_.`____._Total length------ 'D___---_____ - ---------------- /Seepage Pit: Distance to nearest wef)----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material---------------------..Size: Diameter-----------------------Dept h----------------_---------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material____._.___________________________ ❑ Size: Diameter---------------------- ---------------Depth--------------------------------------------------._Liquid Capacity---------------------------gals. 1/1 Privy: Distance from nearest well _______---------------------------------------_Distance from nearest building----------_----------------------------.__ ❑ Distance to nearest lot iire .---------------------------------•-------------------- ----------------------------------------------------------------------- Remodelingand/or repairing (describe):------ '--------------------------------------------------------------------•---------------- --------------•------•---------•------------------------ ---------------------------------------------------------------------------------------------------------------------------------------I-------------------------------------------- --------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------T------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a s, and rules nd regulations of the San Joaquin Local Health District. a• , � e (Signed)----- =------r - - --- -------- {Owner d/or Contractor ---- ----------- -- ---- ------ -- ---------------------- ------------- By:.-. {Title} r`_"` ------- ---- ----- (Plot plan, showing size of lot, location of system to relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ ��-------------------------------------- -------------- DATE----- ' REVIEWEDBY---------- ----------------------------- ------------------------------------------------------------------------------- DATE------------------------------------------- - -------------- BUILDING PERMIT ISSUED--------------------------------------------------------------—-------------------------------------- DATE------------------------- Alterations and/or recommendations:---------------------------------------- ------------------------------------------------•-----•-••----•--------•--•------------------------------------------ ------------------------------- --------------------------------------------- -------------------------------------------------------------------- --------------------------------------------•-•----•-------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------- --•--------------------------------•--•--- ------------------------------ --------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------•------------------- ----------- ------------------ ------------------------------------- ------------------------ ---------------------------------------------------------------------------- -- ------------------------- 0 FINAL INSPECTION BY:Z;4- 1.,_,_>! ------------------------- Date------9_�_ ��/ ................ JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California CS 9 REVISrO 13-59 3M 3-'63 F.P.CO.